Most studies are directed to confirm the causative agent, in the form of serological studies for inflammatory bowel disease, microbial cultures for infectious organisms and metabolic profile for associated co-morbidities

Immunosuppression should be excluded in cases with longstanding infected fistulae

Pathologist most commonly receives a fistula resection specimen, which looks either linear or completely maloriented and may have epithelial lining at one of its edges

The lining may be skin or anorectal mucosa

May be helpful to blunt probe the fistula from the anal mucosal aspect (the primary opening)

May be challenging to find the primary opening due to chronicity and scarring; suggest looking at slightly stretched aspect of adjoining mucosa or viewing a small area with dye that was used to track the fistula during the surgery

There may be many branched secondary openings and therefore a gentle probing of an unfixed specimen may yield better information

Probing should be followed by longitudinal dissection of fistula with pediatric or finer scissors along the inserted probe

Reviewing operative notes or preoperative radiological studies may be helpful

It is also helpful to photograph the specimen in an unfixed state and pay attention to the mucosa adjoining the fistula to look for friable areas or ulcers in a setting of inflammatory bowel disease

Usually there is limited mucosa; if mucosal ulcers are present, then submit the entire area of friability and ulceration to exclude dysplasia associated with inflammatory bowel disease

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